Coding and Reimbursement for Cochleotoxicity and Vestibulotoxicity Services

Abstract

Because of the ICD-10 disease coding system transition that occurred in the United States in 2015, coding and billing for services on behalf of patients who experience cochlear and/or vestibular toxicity may be daunting and misunderstood. Coding and billing for any audiology procedure can be compelling; choosing the appropriate codes for these specific patients is critical not only for payment for services rendered but also for the national and global implications, given their utilization is tracked for mortality and morbidity statistics and potential policies.

With the advent of the International Classification of Disease (ICD-10) coding system transition that occurred in the United States in October 2015, coding and billing for services on behalf of patients who experience cochlear and/or vestibular toxicity may be daunting and is often misunderstood. Coding and billing for any audiology procedure can be compelling, but choosing the appropriate codes for these specific patients is critical not only for payment for services rendered but also for the national and global implications, given their utilization is tracked for mortality and morbidity statistics and health care policies.

This article describes the processes necessary for accurate coding by offering the specific ICD-10-CM disease codes essential for billing cochleo and vestibulo toxicity services, including the codes of the perpetrators of the toxicity, the likely pharmaceuticals/biologicals, and the site(s) of lesion(s) or the condition for which the patient is undergoing treatment. There are two ICD-10 coding systems: (1) the ICD-10-CM code system is utilized by non–facility providers such as those found in independent audiology practices, otolaryngology/audiology practices, and other offices and (2) the ICD-10-PCS is the code system specific to facilities or hospital settings. There is no ototoxic hearing loss code within the ICD-10-PCS system and the author suggests utilizing the hearing loss code(s) that apply to the reason for the test, the signs/symptoms noted in the documentation, and/or the outcome of the test results for that specific patient visit for those patients seen in a facility setting. The rest of this article will address the ICD-10-CM system processes and the necessary components of documentation for these professional services, which may be requested for payment denials, appeals, and other applications.

Note : To locate the ICD-10-CM codes, resources are offered at the end of this article.

How to Utilize the Current Procedural Terminology ^® Codes

The Current Procedural Terminology (CPT ^® ) coding system is the code family composed of a multitude of procedures and services to evaluate patients and manage treatment, including those for cochlear and vestibular functions. The typical CPT ^® codes for cochleotoxic monitoring are, but not limited to, 92557 (comprehensive audiometry threshold evaluation and speech recognition); 92567 (tympanometry); 92585 (auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system, comprehensive); 92587 (distortion product evoked otoacoustic emissions; limited evaluation [to confirm the presence or absence of hearing disorder, three to six frequencies] or transient evoked otoacoustic emissions, with interpretation and report); and 92588 (comprehensive diagnostic evaluation [quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies], with interpretation and report). Currently, there is no specific code to capture ultra-high frequency testing; therefore, the -22 modifier, unusual procedural services, can be appended to the CPT ^® code 92557 or 92552 (pure tone audiometry [threshold]; air only).

The common CPT ^® codes for vestibulotoxic monitoring are, but not limited to, 92537 (caloric vestibular test with recording, bilateral); bithermal (i.e., one warm and one cool irrigation in each ear for a total of four irrigations); 92538 (monothermal [i.e., one irrigation in each ear for a total of two irrigations]); 92540 (basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording; positional nystagmus test, minimum of four positions, with recording; optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording; and oscillating tracking test, with recording); 92546 (sinusoidal vertical axis rotational testing); and 92548 (computerized dynamic posturography).

How to Utilize the ICD-10-CM Codes—Ototoxicity

As a result of the transition from ICD-9-CM to ICD-10-CM which occurred in the United States in late 2015, a new dedicated ototoxic hearing loss code was added in the armament of hearing loss codes commonly utilized by audiologists:

• H91.01 Ototoxic hearing loss, right ear.

• H91.02 Ototoxic hearing loss, left ear.

• H91.03 Ototoxic hearing loss, bilateral.

• H91.09 Ototoxic hearing loss, unspecified.

Any of the aforementioned applicable codes should be utilized if the reason for the patient's visit is due to ototoxic hearing loss or the potential of; a result of a chemotherapeutic agent, an antibiotic regimen; or exposure to a salicylate, nonsteroidal anti-inflammatory drug (NSAID), a diuretic; or if those symptoms have occurred due to exposure to a known ototoxic toxin such as a gas, heavy metal, or solvent; or a combination of any of these. If the patient is experiencing any accompanying symptoms (e.g., tinnitus or dizziness), those also may be coded and placed in box 21 and the corresponding diagnosis pointer in box 24E of the CMS 1500 claim form. You are to code to the highest level of specificity; it is possible that there will be a multitude of ICD-10 codes on the claim form to capture what is noted earlier.

With the transition from ICD-9 to ICD-10, the CMS 1500 claim form was revised and eight additional lines for ICD-10 codes were added, for a total of 12, signified as A-L. The primary (A) code should be the ototoxic hearing loss code that is appropriate, followed by the secondary code (B) which should be the T code (injury, poisoning, and certain other consequences of external causes) that applies followed by the third code (C) as the site of the tumor for anti-neoplastics or for a disease (e.g., Clostridium difficile or MRSA [methicillin-resistant Staphylococcus aureus ]). You will likely need to contact the treating physician's office for the most specific code possible for which the patient is being treated for additional codes beyond the hearing loss code. In addition, if the patient notes tinnitus and/or imbalance, these also can be added to the claim form.

Fig. 1 illustrates a bilateral ototoxic hearing loss code because of the administration of cisplatin for a urogenital cancer. A more detailed step-by-step guide is included later.

Figure 1.

CMS 1500 claim form (standardized claim form necessary to bill Medicare and other payers) with an example of how to utilize ICD-10-CM codes for bilateral ototoxic hearing loss; adverse effect of antineoplastic and immunosuppressive drugs, initial encounter; and malignant neoplasm of urinary organ, unspecified. Contact the patient's health care provider (e.g., oncologist or primary care provider) for their medications and health condition codes.

How to Utilize the ICD-10-CM Codes—Vestibulotoxicity

There is no dedicated toxic code for vestibulotoxicity. If there are vestibular patient complaints, those complaints also can be reported with the toxic perpetrator, and the reason or cause of why the patient is on that medication/biologic or other toxic causative.

Placing the Codes on the Claim Form—a Step-By-Step Guide

• 1. Step 1—The ototoxic hearing loss code as the primary diagnosis code

For those patients diagnosed with one of the applicable ototoxic hearing loss codes (H91.01-H91.09), this code will serve as the primary diagnosis code and will be recognized in two places on the CMS 1500 claim form. The diagnosis code will be placed in box 21 on the A line and the letter A will also be inserted in the CPT ^® diagnosis pointer box 24E next to the CPT ^® code(s). You will need to use at least one additional ICD-10-CM external cause code as the secondary code found in Chapter 19 of the ICD-10-CM Code System to identify the toxic agent(s) and that will be entered in box 21 on the B line and add a “B” in box 24E, also next to the applicable CPT ^® code(s).

• 2. Step 2—T codes: injury, poisoning, and certain other consequences of external causes as the second ICD-10-CM code

This group of codes will result in being the second ICD-10 code on the CMS 1500 form and is placed on line B as well as listed as B in the diagnosis pointer box 24E, next to the applicable CPT ^® code(s). For the secondary code in the example offered in Figure 1, T45.1×5A, A indicates the initial encounter and is utilized for the first time the patient presents to the office for this complaint. For the second time the patient is evaluated for the same condition, the secondary code, the seventh and final place, should be filed as T45.1×5D, with D for subsequent encounter, and for any further visits for the same condition, the secondary code should be filed as T45.1×5S, S for long-term follow-up.

There should be at least one of the codes from the list below from the ICD-10-CM, Chapter 19 on the claim form as depicted on the example in Figure 1. It is possible to have more than one or two of these codes listed below on the CMS 1500 claim form (box 21, line B for the first T code and box 21, line C for a third diagnosis code as well as the corresponding diagnosis pointers in box 24E). Given the range of some of these categories, it will be necessary to contact the attending or ordering physician's office to capture the exact ICD-10 code for those listed below:

• T36.3 Poisoning by, adverse effect of and underdosing of macrolides.

• T36.3X Poisoning by, adverse effect of and underdosing of macrolides.

• T36.3×5 Adverse effects of macrolides.

• T36.5 Poisoning by, adverse effect of and underdosing of aminoglycosides.

• T36.5X Poisoning by, adverse effect of and underdosing of aminoglycosides.

• T36.5×4 Poisoning by aminoglycosides, undetermined.

• T36.5×5 Adverse effect of aminoglycosides.

• T39.0 Poisoning by, adverse effect of and underdosing of salicylates.

• T39.01 Poisoning by, adverse effect of and underdosing of aspirin.

• T39.015 Adverse effect of aspirin.

• T39.09 Poisoning by, adverse effect of and underdosing of other salicylates.

• T39.095 Adverse effect of salicylates.

• T39.3 Poisoning by, adverse effect of and underdosing of other nonsteroidal anti-inflammatory drugs (NSAIDs).

• T39.31 Poisoning by, adverse effect of and underdosing of propionic acid derivatives (includes fenoprofen, flurbiprofen, ibuprofen, ketoprofen, naproxen oxaprozin).

• T39.315 Adverse effect of propionic acid derivatives.

• T39.39 Poisoning by, adverse effect of and underdosing of other nonsteroidal anti-inflammatory drugs (NSAIDs).

• T39.395 Adverse effect of other nonsteroidal anti-inflammatory drugs (NSAIDs).

• T40.3 Poisoning by, adverse effect of and underdosing of methadone.

• T40.3X Poisoning by, adverse effect of and underdosing of methadone.

• T40.3×5 Adverse effect of methadone.

• T45.1 Poisoning by, adverse effect of and underdosing of anti-neoplastic and immunosuppressive drugs.

• T45.1X Poisoning by, adverse effect of and underdosing of anti-neoplastic and immunosuppressive drugs.

• T45.1×5 Adverse effect of anti-neoplastic and immunosuppressive drugs.

• T46.7×5 Adverse effect of peripheral vasodilators.

• T50.1X Poisoning by, adverse effect of and underdosing of loop (high ceiling) diuretics.

• T50.1×5 Adverse effect of loop (high ceiling) diuretics.

• T52 Toxic effect or organic solvents.

• T52.1 Toxic effect of benzene.

• T52.1X Toxic effects of benzene.

• T52.1×1 Toxic effect of benzene, accidental (unintentional).

• T52.1×2 Toxic effect of benzene, intentional self-harm.

• T52.1×3 Toxic effect of benzene, assault.

• T52.1×4 Toxic effect of benzene, undetermined.

• T52.2 Toxic effects of homologues of benzene (toluene and xylene).

• T52.2X Toxic effect of homologues of benzene.

• T52.2×1 Toxic effect of homologues of benzene, accidental (unintentional).

• T52.2×2 Toxic effect of homologues of benzene, intentional self-harm.

• T52.2×3 Toxic effect of homologues of benzene, assault.

• T52.2×4 Toxic effect of homologues of benzene, undetermined.

• T52.8 Toxic effects of other organic solvents.

• T52.8X Toxic effects of other organic solvents.

• T52.8×1 Toxic effect of other organic solvents, accidental (unintentional).

• T52.8×2 Toxic effect of other organic solvents, intentional self-harm.

• T52.8×3 Toxic effect of other organic solvents, assault.

• T52.8×4 Toxic effect of other organic solvents, undetermined.

• T52.9 Toxic effects of unspecified organic solvent.

• T52.91 Toxic effect of unspecified organic solvent, accidental (unintentional).

• T52.92 Toxic effect of unspecified organic solvent, intentional self-harm.

• T52.93 Toxic effect of unspecified organic solvent, assault.

• T52.94 Toxic effect of unspecified organic solvent, undetermined.

• T56 Toxic effect of metals.

• T56.0 Toxic effects of lead and its compounds.

• T56.0X Toxic effects of lead and its compounds.

• T56.0×1 Toxic effects of lead and its compounds, accidental (unintentional).

• T56.0×2 Toxic effects of lead and its compounds intentional self-harm.

• T56.0×3 Toxic effects of lead and its compounds, assault.

• T56.0×4 Toxic effects of lead and its compounds, undetermined.

• T56.1 Toxic effects of mercury and its compounds.

• T56.1X Toxic effects of mercury and its compounds.

• T56.1×1 Toxic effects of mercury and its compounds, accidental (unintentional).

• T56.1×2 Toxic effects of mercury and its compounds, intentional self-harm.

• T56.1×3 Toxic effect of mercury and its compounds, assault.

• T56.1×4 Toxic effect of mercury and its compounds, undetermined.

• T56.8 Toxic effects of other metals.

• T56.89 Toxic effects of other metals.

• T56.891 Toxic effect of other metals, accidental (unintentional).

• T56.892 Toxic effect of other metals, intentional self-harm.

• T56.893 Toxic effect of other metals, assault.

• T56.894 Toxic effect of other metals, undetermined.

• T56.9 Toxic effects of unspecified metal.

• T56.91 Toxic effect of unspecified metal, accidental (unintentional).

• T56.92 Toxic effect of unspecified metal, intentional self-harm.

• T56.93 Toxic effect of unspecified metal, assault.

• T56.94 Toxic effects of unspecified metal, undetermined.

• T57.0 Toxic effect of arsenic and its compounds.

• T57.0X Toxic effect of arsenic and its compounds.

• T57.0×1 Toxic effect of arsenic and its compounds, accidental (unintentional).

• T57.0×2 Toxic effect of arsenic and its compounds, intentional self-harm.

• T57.0×3 Toxic effect of arsenic and its compounds, assault.

• T57.0×4 Toxic effect of arsenic and its compounds, undetermined.

• T57.2X Toxic effect of manganese and its compounds.

• T57.2×1 Toxic effect of manganese and its compounds, accidental (unintentional).

• T57.2×2 Toxic effect of manganese and its compounds, intentional self-harm.

• T57.2×3 Toxic effect of manganese and its compounds, assault.

• T57.2×4 Toxic effect of manganese and its compounds, undetermined.

• T58 Toxic effect of carbon monoxide.

• T58.0 Toxic effect of carbon monoxide from motor vehicle exhaust.

• T58.01 Toxic effect of carbon monoxide from motor vehicle exhaust, accidental (unintentional).

• T58.02 Toxic effect of carbon monoxide from motor vehicle exhaust, intentional self-harm.

• T58.03 Toxic effect of carbon monoxide from motor vehicle exhaust, assault.

• T58.04 Toxic effect of carbon monoxide from motor vehicle exhaust, undetermined.

• T58.1 Toxic effect of carbon monoxide from utility gas.

• T58.11 Toxic effect of carbon monoxide from utility gas, accidental (unintentional).

• T58.12 Toxic effect of carbon monoxide from utility gas, intentional self-harm.

• T58.13 Toxic effect of carbon monoxide from utility gas, assault.

• T58.14 Toxic effect of carbon monoxide from utility gas, undetermined.

• T58.2 Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels.

• T58.2X Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels.

• T58.2×1 Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, accidental (unintentional).

• T58.2×2 Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, intentional self-harm.

• T58.2×3 Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, assault.

• T58.2×4 Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, undetermined.

• T58.8 Toxic effect of carbon monoxide from other source.

• T58.8X Toxic effect of carbon monoxide from other source.

• T58.8×1 Toxic effect of carbon monoxide from other source, accidental (unintentional).

• T58.8×2 Toxic effect of carbon monoxide from other source, intentional self-harm.

• T58.8×3 Toxic effect of carbon monoxide from other source, assault.

• T58.8×4 Toxic effect of carbon monoxide from other source, undetermined.

• T58.9 Toxic effect of carbon monoxide from unspecified source.

• T58.91 Toxic effect of carbon monoxide from unspecified source, accidental (unintentional).

• T58.92 Toxic effect of carbon monoxide from unspecified source, intentional self-harm.

• T58.93 Toxic effect of carbon monoxide from unspecified source, assault.

• T58.94 Toxic effect of carbon monoxide from unspecified source, undetermined.

• T59 Toxic effect of other gases, fumes, and vapors (includes aerosol propellants).

• 3. Step 3—The site of lesion or disease as the third to the twelfth ICD-10-CM code

Box 21, line C and the corresponding diagnosis pointer (C) in box 24E on the CMS 1500 claim form should be at least one of the codes below as depicted in the example in Figure 1. It is possible that there may be more than one of the following and, if so, line D can be utilized and, if necessary, up to and including line L. Given the range of some of these categories, it will be necessary to contact the attending or ordering physician's office to capture the most specific ICD-10-CM code for those listed below as some of these have extensive options given the need for specificity:

• A00-A09 Intestinal infectious diseases.

• A00-A04.7 Clostridium difficile (C-diff).

• A40-A41.9 Streptococcal and other sepsis.

• A49-A49.9 Bacterial infection of unspecified site.

• B50-B54 Plasmodium falciparum malaria and other malaria codes.

• B95-B95.8 Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere. Includes Staphylococcus aureus and MRSA.

• B99-B99.9 Other and unspecified infectious diseases.

• C00-C14.8 Malignant neoplasms.

• C30-C39 Malignant neoplasms of respiratory and intrathoracic organs, including head and neck and lung.

• C34-C34.92 Malignant neoplasms of bronchus and lung.

• C43.2-C43.4 Melanoma and other malignant neoplasms of skin.

• C4A.2-C4A.4 Merkel cell carcinoma of eye, external auricular canal, parts of face, scalp, and neck.

• C44.2-C44.49 Other and unspecified malignant neoplasm of skin of ear and external auricular canal, face, scalp, and neck.

• C47.0 Malignant neoplasm of head, face, and neck.

• C49.0 Malignant neoplasm of connective and soft tissue of head, face, and neck.

• C50-C50.929 Malignant neoplasm of breast.

• C51-C58 Malignant neoplasms of female genital organs.

• C60-C63.9 Malignant neoplasms of male genital organs.

• C64-C68.9 Malignant neoplasms of urinary tract.

• C71-C71.9 Malignant neoplasms of brain and other parts of central nervous system.

• C72.4-C72.59 Malignant neoplasm of acoustic nerve and unspecified cranial nerves.

• C79-C79.89 Secondary malignant neoplasm of other and unspecified sites.

• D00-D00.1 Carcinoma in situ of oral cavity, esophagus, and stomach.

• D02-D02.4 Carcinoma in situ of middle ear and respiratory system.

• D03-D03.4 Melanoma in situ of lip, eyelid, external ear canal and scalp, and neck.

• D03.52 Melanoma in situ of breast (skin) (soft tissue).

• D04.2-D04.22 Carcinoma in situ of skin of ear and external auricular canal.

• D05-D09.9 Carcinoma in situ of breast.

• D10-D11.9 Benign neoplasm of mouth and pharynx.

• D14-D14.4 Benign neoplasm of middle ear and respiratory system.

• D17-D17.0 Benign lipomatous neoplasm and of head, face, and neck.

• D37.0-D37.09 Neoplasm of uncertain behavior of oral cavity and pharynx.

• D38-D38.0 Neoplasm of uncertain behavior of middle ear and respiratory and intrathoracic organs.

• D39-D41.9 Neoplasm of uncertain behavior of female genital organs, male organs, and urinary organs.

• D42-D42.9 Neoplasm of uncertain behavior of meninges.

• D43-D43.9 Neoplasm of uncertain behavior of brain and central nervous system.

• D48.6-D48.62 Neoplasm of uncertain behavior of breast.

• D49.3-D49.6 Neoplasm of unspecified behavior of breast, bladder, outer genitourinary organs, and brain.

• 4. Step 4—Other diagnoses codes for consideration for claims submission/reporting

If the patient notes tinnitus as a complaint and it is included in the chart's documentation, you also can add the appropriate tinnitus code from the list below to the claim form. Looking at the example in Figure 1, one of the tinnitus codes below would be placed in box 21, line 4, on the CMS 1500 form along with the corresponding diagnosis pointer next to the CPT ^® code in box 24E after the ototoxic hearing loss code, the drug/exposure, and the site of lesion/disease.

• H93.11 Tinnitus, right ear.

• H93.12 Tinnitus, left ear.

• H93.13 Tinnitus, bilateral.

• H93.19 Tinnitus, unspecified ear.

• H93.A1 Pulsatile tinnitus, right ear.

• H93.A2 Pulsatile tinnitus, left ear.

• H93.A3 Pulsatile tinnitus, bilateral.

• H93.A9 Pulsatile tinnitus, unspecified ear.

Medical Record Documentation

All the information the patient relays to you must be included in the case history and chart notes in the patient's medical record. Meeting medical necessity is critical for third-party payment and for Medicare Part B, which, at the time of print, also includes a physician order.

The following are critical points of information and must be included.

Adult

• Name.

• Date of birth.

• Address.

• Reason for the visit.

• Past-history including current medications, surgeries, hospitalizations, allergies, recreational and occupational noise exposures.

• Name of the referring provider, if known.

Pediatric

• Family history as well as their.

• Prenatal, delivery information.

• Postnatal histories.

Both Adult and Pediatric

• The patient's health care payer information.

• A notice of privacy practices (NPP).

• Advanced Medicare beneficiary notice (ABN) for Part B Medicare beneficiaries.

• Any other notices required by your state or federal government.

Finally, an interpretation and report of all tests performed, a printout of the tests, and progress notes are also required to be included.

Smart Phone Applications (Both are Free)

• Dr. ICD-10 Chrono ( Fig. 2 ).

• ICD-10 Consult (it will indicate the current year in the logo) ( Fig. 3 ).

Figure 2.

Dr. ICD-10 Chrono.

Figure 3.

ICD-10 Consult (it will indicate the current year in the logo).